Final Case Report- II

Ayesha Arshad (362475)

Internship-I

Submitted to:

Dr. Salma Siddiqui

January 15, 2022

Department of Behavioral Sciences

School of social sciences and humanities, NUST

 Summary

R.A was a 24 years old unmarried female from an upper middle socioeconomic class

family in Rawalpindi. She was first born among two sisters and three stepbrothers. She had

completed her master’s in English Literature and currently, she was staying at home. Client

presented with depressive symptomology including low mood, irritability, lost interest, difficulty

concentrating, and lack of energy, difficulty initiating sleep. Clinically these symptoms were

suggestive of Major depressive disorder. This report is intended to synthesize the data gathered

from the case to provide clinical presentation of client’s problems keeping in mind the nature and

context of these problems.

Identifying information

Name R.A.

Gender Female

Age 24 years

Number of Siblings 5

Birth Order 1st born

Family system joint

Family’s socio-economic status Upper middle class

Qualification Masters in English Literature

Occupation N/A

Marital Status Unmarried

Current residence Home in Rawalpindi

Religion Islam

Date of interview 5st-January-2023

Trainee Ayesha Arshad

Referral and Context

R.A was a 24 years old unmarried female from an upper middle socioeconomic class

family in Rawalpindi. She was first born among two sisters and three stepbrothers. She had

completed her masters in English Literature and currently she was staying at home. Client
presented with depressive symptomology (including low mood, irritability, lost interest,

difficulty concentrating, and lack of energy, difficulty initiating sleep and suicidal ideations).

Client was approached to take part in clinical interview for educational purpose. The purpose of

this interview was to complete the writer’s educational requirement for course of Clinical

Internship-I. Informed consent obtained from client is attached in Appendix A.

Client presented with symptoms of disturbed functionality however, information

provided by her was informed and reliable therefore, she was a credible historian.

Presenting complaints

During the interview client reported, that she had been experiencing “low mood and

restlessness along with excessive worry”. “Excessive guilt” around her relationship with her

boyfriend was also reported by client. She also reported that she had “lost interest” in the routine

activities, including socializing with friends and playing sports which, he used to. She also

reported “difficulty initiating sleep, irritability, difficulty concentrating in activities”. She also

reported being “preoccupied with thoughts” around her future

History of Present Illness

Client reported that her home environment remained “conflictual” as her mother passed

away in her childhood when she was around 10 years old. Her father remarried, and initially she

could not accept her stepmother. She reported that she always had a conflict with her father

regarding this matter as she did not want anyone to take her mother’s place, she was scared of

being neglected by her father. Client reported that his father was never there for her and her

sister, he never paid attention to their needs. Slowly she realized that she could not do anything
about this and she made her “peace” with this. She reported that the environment was bearable

because of her grandmother and her sister.

Client reported that since 2014 while was in her F.s.c she liked a guy M.A in her neighborhood.

M.A’s parents brought proposal to the client home, but her father refused by saying that they

didn’t marry out of the cast, but client continued her contact with him as she could not “live”

with him, he was the only source of happiness in her life.

In 2018 client’s grandmother passed away which was the most “traumatizing” experience of her

life. She started feeling lonely and isolated. Her home environment became “unbearable” for her

she would always feel “suffocated”, she wanted to just “run away” from there. She reported that

there were so many “restrictions” in her home which she didn’t like, she was not allowed to go

anywhere alone as women were always accompanied by male members in her family. She had to

struggle for every minor need. Initially her father did not allow her to continue her studies. Client

became “Hopeless” because of this, her future seemed to be “dark”. That was the first time when

she wanted to kill herself, she “drowned herself in overthinking”. Her paternal intervened and

convinced her father to let her study further. Client reported that when she joined university, she

became very bus with her studies and her life became somewhat “peaceful”.

In 2019 her father engaged her to one of his friend’s sons. She tried to resist but they

“forcefully” engaged her, client reported that she could never accept that relationship and kept

planning how she could get marry to the “love of her life”. Client reported that her home

environment was really disturbed as her family often taunted her for her stubbornness. In the

meanwhile, she discovered that M.A. got engaged. After hearing this news, she felt betrayed, she

was really distressed and hopeless. She reported that she could not concentrate on anything, she

could not sleep as she would just keep thinking about her future.
 Client reported that after that She tried to adjust with her fiancé, but he was a drug addict

and had affairs. One of her fiancé’s girlfriends contacted the client and asked her to break the

engagement. She told this to her father, the situation got worse, and her father came to know

about the boy alcohol drinking, so he broke the engagement in March 2021. Meanwhile, M.A.’s

engagement was also called off and client patched up with him. This was momentarily relieving

for her However, client’s family kept blaming her that she never put efforts in her engagement

relation and created problems to call off the engagement. Client reported that she got disturb

again, felt resentment, sadness, and worthlessness. Her sleep and appetite got disturbed. She had

frequent crying spells. Her BP started remaining low. Her sister took her to a physician who gave

her some sleeping pills and antidepressants after which her sleep got better. The client reported

that during the whole distressing period the M.A. did not give any emotional support.

In February 2022, her father was finding a match. She again asked him to consider the

proposal of guy whom she liked but her father again and his uncle also supported her.

She was hopeful that this time her father will accept the proposal, but his father again rejected

the proposal as the M.A. was not according to his standards. She got disappointed and talked to

her father about M.A. family’s visit to their home. Her father rebuked her and suggested her not

to marry him. M.A. was started insisting her to do court marriage, but the client was confused

about it. She reported that at that time she started experiencing loss of interest in everything

including M.A. and there were frequent crying spells and helpless. She did overthink a lot at the

time but was unable to reach any decision.

In March 2022 she went to a clinical psychologist and discuss all the scenario with her,

but she only took one session with the clinical psychologist. The client wanted to continue the

therapy, but her family and father criticized her for going to a psychologist and said that
‫اب ھمارے گھر کی بچییاں جائیں کی دماغ کا عالج کروانے‬،‫ شفا لینے‬،‫لوگ ہمارے پاس آتےہیں اپنے مسلے حل کروانے‬

‫تو کیا عزت رہ جائے گی۔‬

The client reported that after that she started contemplating about the option of court

marriage. She was in much confusion as she was unable to decide whether she wanted to

continue relationship with M.A. or leave him. She had no one with whom she could share things

and get advice. She tried to find out solution, but situation got worsen day by day. She lost

interest in daily activities, negative thinking prevailed (start feeling no one loves or care about

her, she is the one who put effort in every relationship but never gets anything positive back,

feeling of worthlessness), her sleeps got disturb and she felt helpless.

She also contemplated on the option to leave M.A. and obey her father but she felt guilt

over breaking 8 years old relation and apprehended that M.A. would blame her and maybe she

could not get attach to any other man like she was attached to M.A. While giving history she

reported to that she has better options than M.A. but “He does not have any option other than her

and he just want to win her like a trophy”. They both have no idea what the goals of their

married life were. Their future seems bleak to her. flashbacks of every negative and painful

events from the childhood crosses her mind. She thinks that her father and M.A. both were

selfish to her as they only took care of their ego and never considered her feelings. She wanted to

stop thinking but unable to stop the negative thoughts. All these have been aggravated since past

two months and she feels quite hopeless about her future.

Risk Assessment

Client reported rumination and hopeless ness however suicidal tendencies, or self harm

behaviors were denied

Premorbid Personality
 Client was generally calm-tempered and companionate towards others. She had a good

sense of humor and social skills. She interacted easily with the people. There were always

ordeals in her life, but she tackled with them smartly. She was very religious, often pray nafals

and seek help from Allah whenever she was in trouble. She used to watch movies, read books

and talked to her friends whenever she felt distressed. The client reported that she used to do

painting and sketching and found it so therapeutic. She used to sit with her family but now

avoids. She used to meet guests. She used to cook and do household chores. She liked to read

books.

Academic history

Client started her schooling at the age of 5 years from nursery. She adapted the

atmosphere easily in school and made friends. She was not much talkative. She had satisfactory

relationships with her teachers. She did not take part in co-curricular activities. She adjusted well

with her classmates and had satisfactory relationships with them. After matriculation, she got

admission in college and adjusted soon. Throughout, her academic career her grades have been

excellent. She wanted to become a doctor, but she did not get admission in MBBS due to low

marks in MDCAT. Her father offered her to do MBBS privately, but she did not want to do it

privately. She did BS hons in English literature and MA in political science. She did not make

any close friend in university. After graduating she wanted to do M pill, but her father did not let

her do so. So, she started preparing for CSS, but her preparation got disturbed by her illness.

Occupational History

The client never did any job. She wanted to become financially independent, but her

father never let her do so.

Sexual History
 Client achieved menarche at the age of 14 years and had prior knowledge of it from her

elder cousins. She adjusted well with the pubertal changes. She had a romantic relationship with

a boy but she reported that “she never crossed the line”. Client reported that she never took

intertest in anybody else other than M.A but he was “insecure and possessive” about her that

she sometimes felt ‘suffocated”.

Family history

Client’s father was 66 years old, businessman and educated up till masters. He was a

“Peer” and took care of the tomb of his father. Client reported that “He was aggressive and

egoistic in nature”. And she had “love hate” relationship with him.

Client’s mother passed away when the client was 10 years old. Client had little

recollection of her mother.

The client father remarried after client’s mother death. Initially client faced difficulties in

accepting her as her father’s wife. Client had formal relationships with her. Her stepmother did

not interfere much in their matter. She had “quite and submissive nature” and did not have much

concern about what was happening in the home. client’s father and her stepmother had

conflictual relationship. Client reported witnessing her father physically abusing her stepmother.

Client reported being “disappointed” in her father.

1st born siblings was the client herself. 2nd born is a 21-year-old sister educated up till

graduation. She got married in December 2021. She had friendly nature and had very good sense

of humor. Her sister acknowledges the client efforts for her. She had amiable relationships with

the client and the client shared things with her. The client reported she missed her after her

wedding.
 Youngest one was 18-year-old sister. She was studying in university. She had a quiet and

caring nature, but the client didn't have much sharing with her due to age difference.

The client had 3 stepbrothers who studied in school in 7, 5 and 3rd class respectively. The

client reported that her stepmom did not like if she or her sisters try to get close with them, but

she still loved and care about them. The client did not have much sharing with them as they were

younger enough.

General Home Environment

The client lived in a joint family system. The overall home environment was stressful and

conflictual. There was a lot of interference of other relativeness specially her maternal aunts in

their house. Major authority figure and breadwinner of the house was her father. They belonged

to an upper-class family and the family was very religious. Once in a year there was Urs in their

home and they provided generous hospitality to hundreds of followers.

History of Psychiatric Illness in Family

No significant psychiatric illness was reported in the client’s family.

Strength and Coping strategies

Client appeared to be an ambitious and motivated person before the development of

symptoms. She had an interest in extra-curricular creative activities. Additionally, religious

coping was evident

Mental Status Examination (MSE)

She was a young girl of average weight and height. She was wearing weather

appropriate but unpressed clothes. She had dark circles under her eyes. Her mood appeared to be
low which was congruent with her affect. She spoke in a low tone. She seemed gloomy. She

started crying immediately after she sat down in front of the trainee. But time to time, during the

session, she cried her eyes out while giving history of present illness. She maintained eye

contact. She was cooperative and seemed to comprehend what the trainee told her. She had short

hairs which was tied in a band. She also untied the band to show that she had cut her long hairs

in frustration, anger, and anxiety. Perceptual disturbance like hallucinations, depersonalization,

and derealization were not reported. She also did not report any delusions, obsessions, or

compulsions. Her orientation of person, place and time was intact, but the attention and

concentration were partially intact. Abstract thinking and insight about her illness were also

present. At the end of the session, she also thanked the trainee to comprehend her point of view

as nobody else could or never tried to understand her. Indicating her lack of social support

Summary and conclusion

.A was a 24 years old unmarried female from a lower middle socioeconomic class family in

Rawalpindi. She was first born among two sisters and three stepbrothers. She had completed her

masters in English Literature and currently she was staying at home. Client presented with

depressive symptomology including low mood, irritability, lost interest, difficulty concentrating,

and lack of energy, difficulty initiating sleep. Client’s history and MSE revealed several factors

which can be attributed to his presenting complaints i.e social, familial, personal. Avoidant

coping strategies were noted which were also contributing to his current symptoms. Client

appeared to be an ambitious and motivated person pre-development of symptoms. She had an

interest in extra-curricular creative activities. Additionally, religious coping was evident

Diagnostic Formulation
The presenting complaints of the client are suggestive of 296.22 (F32.1) Major

Depressive Disorder indicated by

 Depressed mood

 Loss of interest

 Disturbed sleep

 Difficulty concentrating

 Fatigue

 These symptoms appear to have caused significant impairment in the client’s daily

functioning i.e., social, familial, and academic.

Keeping all of the above-mentioned symptoms in view and the duration (since past two months),

the provisional diagnosis can be major depressive disorder.

Differential Diagnosis

Persistent depressive disorder was ruled out as client had been experiencing the

symptoms for almost a month and the previous episodes (when he came to hostel) was also less

than two years old i.e., occurred one year ago.

Anxiety and related disorders can also be accessed as client reported excessive worry and

restlessness. However, client’s symptoms seem to be attributed to the tobacco consumption as he

has experienced these symptoms after consumption or withdrawal.

The client was assessed for manic episode with irritable mood or mixed episodes as she

had reported “irritated mood”. However, she denied any history of elevated mood, inflated self-
esteem, decreased need for sleep, more talkative than usual or any of the related symptoms.

Therefore, Bipolar Affective disorder was ruled out.

Client was assessed for obsessive-compulsive disorder as she reported being preoccupied

with thoughts and they were causing significant distress. However, these thoughts did not appear

to be intrusive, they seemed to be a manifestation of rumination. The thoughts were mood

congruent, as she had those thoughts mostly when she was “sad”. Therefore, OCD was ruled out.
Case Formulation

R.A was a 24 years old unmarried female from an upper middle socioeconomic class

family in Islamabad. She was first born among two sisters and three stepbrothers. She had

completed her masters in English Literature and currently she was staying at home. Client

presented with depressive symptomology (including low mood, irritability, lost interest,

difficulty concentrating, and lack of energy, difficulty initiating sleep). Clinically these

symptoms were suggestive of Major depressive disorder.

Client’s vulnerabilities can be traced to her early life experience. She grew in a discorded

home environment where she seemed to be constantly on a survival mode. Losing her mother

was already a predisposing factor for her vulnerabilities which may had developed the core belief

of abandonment. She perceived her father as unjust and cruel, and her home environment as

suffocating which may had nurtured negative beliefs about herself (I am worthless) others (they

are cruel, they will leave you) and the world (world is unjust) were developed. Further

dysfunctional assumptions and beliefs “I can never please my father, I want his approval” Or “ I

am unlove able, worthless and never find love” seemed to develop. these beliefs activated when

she faced any negative event later in her life, resulting in emotional, cognitive, and behavioral

reactions. Not being appreciated by her father despite trying hard may had fostered belief about

not being good enough which was also apparent in form of rejection sensitivity (fear of that

others will not accept her, excessive compliance with boyfriend as well as interviewer) and lower

self-esteem. Client also seemed to adopt a shy and reserve temperament and avoided

unnecessary social contact which appeared to be another predisposing factor for her. Excessive

criticism also seemed to inculcate doubts about his self-efficacy and seemed to lower her self-
esteem. It also seemed that client was trying to find the warmth and affection in relationships

which she desired from her family as indicated by excessive compliance with boyfriend.

A number of critical events occurred where client’s negative beliefs seemed to be

activated i.e., when her father engaged her forcefully, when her boyfriend got engaged.

Ignorance from her boyfriend nurtured her core belief of abandonment. Death of grandmother

further precipitated the situation. This also perpetuated a fear of uncertainty for client. Client

adopted rumination which escalated catastrophizing thought pattern. The fear of abandonment

exacerbated over compensatory behaviors towards the boyfriend, which trended to encourage her

returning to her relationship. Client went out of the way to be with her boyfriends as she had

internalized the fact that she is not going to get happiness and she feared being isolated. Being at

home and not doing anything perpetrated lethargy and client started losing interest in other

activities too. Deficiency of adaptive coping strategies and low social support also contributed

towards development of symptoms

Treatment Formulation

Treatment plan can be formulated based upon the following factors:

 Restoring her self-esteem by making him realize via motivational interviewing and

rationalizing and shifting her attention to her strengths.

 Emotion regulation strategies to manage emotions and processing of break up, social

skills to make friends who will have good influence, problem solving strategies including

distress management.

 Resumption of recreational activities to form healthy coping strategies.

 client's symptoms appear to be a presentation of her "trait" more than state as indicated

by her premorbid history; therefore, the personality features need to be further examined

and kept into consideration for treatment planning.

 Cognitive behavioral therapy can be adopted as well with the underlying idea to change

the thought patterns that are disturbing the client’s life. This might happen through

identifying the underlying automatic thought thoughts and beliefs from which they

originate (which might be belief of incompetency or abandonment)